The possibility of setting a maximum age limit for GHS service providers, restrictions on the inclusion of new providers, the possibility of collection by insurance companies and a significant increase in administrative fines, are provided for by two bills that are already in the process of public consultation.
The amendments to the GHS law also include payment audits over a period of up to 12 years in cases of fraud, the possibility of recovering amounts paid in violation of the prescribed conditions and the expansion of the audit powers of the Health Insurance Organization (HIO).
The provision for the age limit is included in Article 25 of the second amending bill.
It generally concerns persons who provide health care services through the GHS and is not explicitly limited to a specific medical specialty or professional category.
The amendment essentially comes to respond to the occasional discussions regarding the age of personal doctors.
This issue has also occupied both the public debate and the Parliament in previous years.
The proposed text does not mention whether a possible age limit will be uniform for all providers, whether there will be exceptions or whether transitional arrangements will be provided for those who are already contracted with the HIO.
The same article also provides for the possibility of determining a procedure for the reintegration of persons into the GHS after cancellation of registration or termination of a contract.
The relevant provision refers to "determination of the procedure, terms and conditions for the reintegration of persons into the System following the cancellation of registration and/or termination of a contract for the provision of health care services".
The HIO will be able to refuse the inclusion of new providers
Significant changes are also included in the second amending bill, which focuses mainly on the responsibilities of the HIO for determining the needs of the System and the registration of providers.
With the amendment of Article 38, the Agency will be able, under the conditions set by the proposed provision, to refuse registration in the GHS or the conclusion of a contract with natural or legal persons.
The bill provides for the possibility: "to refuse registration in the System and/or the conclusion of a contract".
This power is linked to the determination of the needs of the GHS and to reasons of public interest related to the coverage of the needs of the beneficiaries, the quality of services, the economic viability and the protection of public health.
The first bill provides that the HIO will be able to: "set as a condition the registration in the System and/or the conclusion of a contract, the acceptance of defined terms and/or restrictions".
At the same time, the HIO will be able to "set conditions and/or restrictions on the provision of health care services". The second provision also applies to persons who have already entered into a contract with the Organization, as well as natural persons who provide services on behalf of contracted providers.
The bill clarifies that the determination of needs and restrictions will be done by Internal Regulations, while the observance of the principles of proportionality is provided.
In addition, the HIO will be able to refuse or cancel the registration of natural persons who provide services on behalf of providers, if they do not meet the prescribed requirements.
In practice, with this change, the HIO will be able to choose, based on the needs of the beneficiaries, the inclusion of providers of specific services or the rejection of requests for inclusion in cases where the System already has a large number of professionals.
Fines of up to €600,000 for repeat infringement
The framework of administrative sanctions of the GHS is also becoming stricter.
With article 23 of the second amending bill, it is proposed to amend article 63 of the basic law, so that the maximum administrative fine is increased from €30,000 to €300,000.
An even larger fine may be imposed in case of repetition of the violation.
"To impose, in case of repetition of the violation, an administrative fine, depending on the nature, gravity and duration of the violation, the amount of which may not exceed six hundred thousand euros."
These are maximum fines and not amounts that will be automatically imposed on each violation.
Payment checks over 12 years
One of the most important changes concerns the possibility of checking claims of providers that have already been paid by the HIO.
With the addition of the new article 39A, the Director-General will be able to carry out ex-post checks.
According to the bill, "the general manager may carry out ex post audits on claims submitted by providers and paid by the Agency, within three years from the date of their payment".
This period extends to cases where it is established that the infringement occurred as a result of intent.
Specifically, the bill provides that the Director-General will be able to carry out the relevant checks: "as if the reference to three years in paragraph (1) were a reference to twelve years".
The period of 12 years does not therefore relate to all payments, but is linked to the finding of an infringement resulting from deception.
The Agency, as foreseen, will also be able to recover amounts already paid, if a documented infringement occurs.
Violations may concern the legislation, Regulations, Decisions and Circulars of the Organization, as well as clinical protocols, restrictions, criteria, quality standards and contractual terms.
This means that payments that have already been made can be reviewed and, if a breach is found, corresponding debts can be established.
The audit powers of the HIO are being expanded
In addition to financial audits, the second bill also amends Article 39, expanding the framework for investigating possible violations.
The proposed powers include gathering information, checking documents and electronic records, and inspecting providers' facilities.
The bill includes an explicit reference to the possibility: "to enter, search and inspect facilities".
At the same time, there are powers to seize or take copies of documents and files, as well as to obtain information from persons related to investigated cases.
The amendment also extends the scope of controls to the implementation of clinical guidelines, protocols and quality standards.
In particular, it provides for a control of the implementation of "clinical guidelines, protocols, restrictions, terms and conditions, criteria".
Changes in the replacement of personal doctors
A significant differentiation is also proposed in the way personal doctors are remunerated when a substitute service is provided.
With the replacement of Article 27, it is provided that for the services that will be provided to beneficiaries during the replacement, the fee from the HIO will continue to be paid to the personal doctor in whose list the beneficiaries are registered.
As stated: "The personal doctor who has the beneficiaries registered in its list is remunerated by the Organization."
At the same time, it is expressly provided that: "The Organization will not pay any additional remuneration to the personal doctor who provides the substitute service".
However, personal doctors will be able to make financial arrangements with each other.
'Personal doctors may, if they so wish, reimburse the personal doctor whom they appoint to provide a substitute service'.
The cases of replacement, the conditions and the implementation procedures will be determined by Decisions.
Annual payments from insurance companies
New financial obligations are also provided for insurance companies. With the addition of article 55A, insurance companies will be obliged to pay annually to the HIO amounts corresponding to part of the GHS expenses for accidents or occupational diseases, provided that these are covered by compulsory insurance coverage.
The relevant provision states that: "insurance companies are obliged to pay annually to the Organization".
The distribution of the amounts will be made: "according to the market share of each insurance company".
The relevant provision comes to fill the huge gap that currently exists and concerns, among other things, the coverage of the services received by GHS beneficiaries after traffic collisions by the HIO at a time when all drivers in Cyprus are required by law to have insurance coverage.
Strengthening internal control
Changes are also foreseen in the internal operation of the HIO.
With the addition of article 60B, an internal audit framework is introduced and the operation of an Audit and Public Governance Committee is provided.
The responsibilities of the Internal Audit Unit include:
"Carrying out audits on the basis of an approved annual control programme".
At the same time, special studies and ex officio audits are provided for issues that may affect the financial viability, integrity and operational efficiency of the Organization.
In addition, the HIO Council will be able to temporarily transfer powers and responsibilities, under its control and within defined limits.
